What Will Replace Opiates?

Prescription opiate medication for chronic pain is a treatment whose time is ending. To quote Dr. Tom Frieden, director of the Center for Disease Control (CDC), for most pain patients the benefits of opiate painkillers are “unproven and transient” and they can be “just as addictive as heroin.” In addition, annually since 1999, ten thousand people have died from overdoses of prescription painkillers. The pain management community has concluded that, apart from people with cancer pain or those at the end of life, opiate painkillers have become a public health crisis. The CDC now recommends against using them for most non-cancer patients.

Regrettably, national leaders in this field have not recommended any useful alternatives to prescription analgesics. As Mayo Clinic Addiction specialist Dr. Jon Ebbert put it: “Unfortunately, medicine is in desperate want of cost-effective non-opioid pain control modalities.”

Dr Ebbert is misinformed, of course. Clinicians experienced in treating psychophysiologic disorders (PPD) routinely provide cost-effective non-opioid pain control care to their patients. Even a small subset of the range of measures used by PPD clinicians is more effective than usual care as a recent randomized trial with chronic back pain patients (reviewed in the New York Times) (1) demonstrated.

In this study from the Group Health Research Institute and the University of Washington in Seattle, 342 patients with low back pain for an average of over seven years were randomized to receive one of the following:

Usual Care (UC)

Usual Care + Mindfulness-based Stress Reduction (MBSR)

Usual Care + Cognitive Behavioral Therapy (CBT)

MBSR and CBT were provided to groups for up to two hours weekly for eight weeks. Eighteen weeks after the sessions clinically meaningful improvement in disability was found in 61% of MBSR and 58% of CBT patients vs only 44% of UC patients. Clinically meaningful improvement in how bothersome the pain felt was found in 44% of MBSR, 45% of CBT but only 27% of UC patients.

At one year follow-up the MBSR group’s improvement persisted with little change although the benefit of CBT was no longer statistically greater than UC. This is consistent with my own experience that CBT alone tends to be less effective for achieving long-lasting improvement.

The superior outcomes for MBSR and CBT occurred despite the fact that only 50% of subjects attended at least six of the eight treatment sessions. (If these patients had received individual assessment for repressed negative emotions, I suspect they would have found the information more compelling.)

An editorial (2) by an internal medicine physician and a psychologist in the same issue of JAMA concluded, and I couldn’t agree more, that these results “create a compelling argument for ensuring that an evidence-based healthcare system should provide access to affordable mind-body therapies.”

Experienced PPD clinicians have learned that the best outcomes are achieved by helping patients accomplish the following:

Recognize repressed negative emotions (and their sources).

Express those feelings in words.

Howard Schubiner, Mark Lumley and colleagues have just completed a randomized trial of this Emotional Awareness and Expression Training that showed outcomes superior to CBT in fibromyalgia patients. As clinicians look for evidence-based alternatives to opiates for chronic pain, this is an idea whose time has arrived.